MEDICARE: OLIVE BRANCH DENTAL GROUP PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	233887	MS

General Provider Information

NPI Number	:	1174072409
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLIVE BRANCH DENTAL GROUP PLLC

Provider Business Mailing Address
First Line	:	7271 GOODMAN RD
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-1906
Country	:	US
Telephone Number	:	662-895-4737
Fax Number	:

Provider Business Practice Location Address
First Line	:	7271 GOODMAN RD
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-1906
Country	:	US
Telephone Number	:	662-895-4737
Fax Number	:

Authorized Official
Title or Position	:	BUSINESS OFFICE
Name	:	DEBBIE K SHIELDS
Credential	:
Telephone Number	:	662-840-1535

Provider Enumeration Date	:	09/28/2016
Last Update Date	:	09/28/2016

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